Evaluation of a Serious Video Game to Facilitate Conversations About Human Papillomavirus Vaccination for Preteens: Pilot Randomized Controlled Trial

"Gamification has the potential to increase engagement with health messaging relevant to shaping motivation and behavior, such as seeking HPV vaccination..."

Although many interventions promoting human papillomavirus (HPV) vaccination have focused on parental beliefs/attitudes or provider recommendations separately, it is increasingly being recognised that a multilevel approach may hold potential to increase uptake. In countries such as the United States (US), suboptimal uptake of the HPV vaccine, even though it is recommended for routine use in those aged 11 to 12 years, puts young people at risk of a sexually transmitted infection that has health-related impacts such as cancer. This paper describes and evaluates an educational video game called Land of Secret Gardens - also detailed at Related Summaries, below - that was designed to educate preteens about HPV vaccination and to promote conversations with parents and providers about the decision to vaccinate.

The game was created as part of the Protect Them study, which was undertaken in 36 primary care practices with 97 providers in North Carolina, US. This was a multiple baseline study and included 3 waves of activity and adjustment in 2015, 2016, and 2017. Communication tools included brochures, posters, web-based information for parents, and interactive web-based training for providers. As part of the intervention, the researchers provided select patients access to the Land of Secret Gardens, which incorporated gamification elements (e.g., points, badges for completion of tasks, and a leaderboard) meant to increase vaccine self-efficacy (i.e., confidence in getting the vaccine despite barriers). Self-determination theory was also used to inform the game design. The game included an immersive story about a secret garden as a metaphor for a preteen's body and keeping it healthy. Throughout, players were exposed to messaging about HPV and the benefits of the vaccine.

For the study, the researchers screened 131 dyads of parents and preteens who had not initiated HPV vaccination. They measured vaccination intentions, story immersion, and game play and documented HPV vaccination rates. Fifty-five dyads were enrolled, 28 of whom (21 completed) were randomly assigned to play the game, and 27 of whom (26 completed) constituted the comparison group.

Of the 18 preteens who reported playing the game, the vaccination self-efficacy score was higher in the comparison group than the intervention group (1.65 vs 1.45; P=.05). The overall mean decisional balance score trended toward greater support of vaccination, although differences between the groups were not significant. Vaccine initiation and completion rates were higher in the intervention group (22% vs 15%; P=.31) than in the comparison group (9% vs 2%; P=.10), although the difference was not significant.

More than half of the 18 game players gave positive scores on game autonomy and competence, ease, and freedom of playing the game. At the same time, many called the game boring, said they were not impacted emotionally, and indicted that the game did not hold their attention. More qualitative evidence comes from the 3 focus groups the researchers conducted with 7 preteens following each of the 3 waves in the intervention. The preteens generally enjoyed and understood the game, acknowledged that playing the game helped them to be more aware of HPV, and said the game was easy to play and fun. That said, the preteens could not remember specific messages in the game, and study participation did not impact their attitudes about HPV vaccination. They provided suggestions for refining the game, such as including more activities beyond the shield game and the hidden objects.

Based on the findings, the researchers conclude that "A serious video game on HPV vaccination is acceptable to parents and preteens and can be played as intended. Gamification can be effective in shaping attitudes about the HPV vaccination. Further research is needed to enhance the game with puzzles and activities that are engaging to the preteen population."